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IMAGINE a health system in which one particular body part was carved out of medical training and normal care arrangements, with treatment provided only to those who could afford to pay for it.
The eye perhaps. The skin. Or the heart.
We’d think such a system ridiculous, and it would be; yet, that is arguably what has happened with oral care.
The world’s first university dental school is said to have been established at the University of Maryland in 1840 by two largely self-trained dental practitioners, one of whom was also a medical doctor.
The two dentists, the story has it, had earlier approached the university’s medical school with a request for dental instruction to be added to the curriculum.
The schism between medicine and dentistry may have had its origins right there.
According to a version of the story recounted in health journalist Mary Otto’s book, Teeth, the doctors rebuffed the dentists’ overture in a letter saying “the subject of dentistry was of little consequence”.
The Baltimore dentists went their own way and so it has been ever since.
Dentistry’s separate status has led to it being seen as an optional extra – literally so in private health insurance policies – rather than an essential part of the health care system.
Inevitably, the resulting health burdens fall disproportionately on those who can least afford to pay.
A report from the Grattan Institute last week brought into stark relief the inadequate and inequitable provision of dental care in this country.
It’s hard to imagine anybody on a multiyear waiting list for public dental care in 21st century Australia would see the subject as being “of little consequence”.
Around two million Australians who needed dental care in the past year delayed or did not get it at all because of the cost, the Grattan report found. A quarter of Australian adults had to avoid some foods because of the condition of their teeth and for low income adults, it was more like one in three.
It may be outside the scope of the report, but it’s also true that good teeth are a highly visible marker of social status in our society, further entrenching disadvantage for those who can’t afford proper care.
If two people come in for a job interview, one with a row of ragged stumps in their mouth, the other with a gleaming smile, which one is more likely to get an offer?
The Grattan report argues the federal government needs to take responsibility for ensuring all Australian have access to dental care by moving towards a Medicare-style universal primary dental scheme.
“There’s no compelling medical, economic, or legal reason to treat the mouth so differently from the rest of the body,” the authors say.
Full implementation of such a scheme would cost about $5.6 billion a year, they estimate, suggesting the scheme would need to be phased in over a decade.
It’s true the dental profession might not be entirely supportive of such a proposal. After all, a universal public scheme would likely exert downward pressure on fees.
Public health policy, though, should not be determined by vested interests but by the interests of, well, public health.
Barriers to accessing preventive dental care, and prompt treatment when problems arise, contribute to worse outcomes and higher costs down the track.
Untreated dental conditions can even be fatal, as in the tragic case of 12-year-old Maryland boy, Deamonte Driver, who died in 2007 after the infection from an untreated tooth abscess spread to his brain.
More broadly, it’s well known poor oral health can contribute to other health issues, including diabetes and cardiovascular disease (here, here and here).
A more integrated health system could deliver benefits beyond healthier teeth.
It’s been suggested, for example, that periodontitis might be a warning sign for type 2 diabetes, meaning dentists with a solid grounding in systemic health could play a role in early diagnosis of that condition.
It’s interesting to wonder how different things might have been if those 19th century medical men in Baltimore had been more open-minded about their dental colleagues.
Jane McCredie is a Sydney-based health and science writer.
The statements or opinions expressed in this article reflect the views of the authors and do not represent the official policy of the AMA, the MJA or InSight+ unless so stated.
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Eye ears throat used to mean something. Heavy anti-biotic treatments that I was given were a pointless attack on my body – I was already heavily depressed – months later after suffering outbreaks on my skin, I made it into a dentist. All my problems went away in a month after extracting a bad molar, that hadn’t been painful.
It’s @#E$ absurd. I must be a filthy bastard is the attitude I got. Brilliant.
Sri Lanka as a middle income developing country provides a unique model of public oral health care provision as all specialized oral health care such as Oral & Maxillo-Facial surgery, Restorative Dentistry, Orthodontics and Preventive Dentistry as well as general dentistry provided free of charge at the point of service delivery highly integrated into the existing public health care infrastructure. It is a unique model of Universal Health Coverage.
As a dentist I grew up in a medical household. It was patently obvious to me why doctors don’t talk about teeth. It’s outside their scope of practice, and dentistry is outside medicine and health care.
The need for dental treatment is visible even to a lay person. However, the need for an oral or dental intervention for medical reasons is often invisible, This can include harmful bacteria, pathology, oral dysfunction and conditions. These are clearly relevant to the doctor. How can a doctor competently manage a medically compromised person without having available diagnostic and treatment services? They can’t. And it is legislated these essential; services will not be included in primary health care.
Those most affected by this legislation are the medically compromised and those requiring care, both medical and nursing priorities. They are the highest medical risk groups, known to have the worst oral health, least likely to seek dental care, and cost the most. They see doctors but not dentists. I have spent almost 40 years in areas unserviced by dentists alongside nurses and doctors not providing dental treatment but assisting them in managing daily oral care. I have found the teeth are not the problem but the ineffective practices which can exacerbate the problems. The consequences of this are the patient gets sicker, requires more medical and nursing interventions, their quality of life and dignity rapidly diminishes, everyone gets frustrated, and health care costs a lot more. The other observation I must make is all too often their last days are the worst because of dental pain or an intractable mouth problem. This is all PREVENTABLE.
Unlike other health care, oral care is considered personal care or hygiene when clearly it is not. The Right to Health is a fundamental human right. There are no exclusions. It guarantees universal access to essential health care and the obligation to ensure everyone is ‘as healthy as possible’. Legislators have an obligation to ensure legislation does not impact adversely on vulnerable groups, and protects them. This doesn’t..
Dental necessary dental care is dentistry. Medically necessary dental care is essential health care. Both Medicare and Charter of Health Care Rights legislation MUST be amended because the exclusion of oral health from health care is defective, discriminatory, and inequitable legislation. Both sides of politics need to respond to this.
The solutions are simple, affordable, and non negotiable and consistent with international health policy. Amend the legislation. Integrate oral health within primary health care under a medical umbrella to address the health care issues. Address oral health in health care as an essential clinical discipline. Promote prevention and wellness. Practice holistic multidisciplinary care- get out of the silo.
Then you will be delivering quality health care as required by the Charter of Health Care Rights.
Mention was made as to the public health component. One of the most effective tools, apart from the twice daily use of tooth brush, is fluoride supplementation of the drinking water. It is well recognised that you pick those persons who were raised in towns with supplementation and those who never received fluoride.
If dental care is to be opened up to the Federal sphere, then councils must be denied the opportunity to refuse water fluoridation and thus not to assist the persons in their communities to have better health through better teeth.
Those who do not want fluoride can put in a device, at their expense, to exclude it.
An area where Dental pathology is rampant, is Western Qld, and NW West Australia eg. Broome. Mostly the indigenous peoples, but plenty of “white fellas” also.
I would guess, most of Country and Provincial Australia.
I mention these areas because I have practiced there.
One answer, would be Mobile Dental Clinics, like that Cardiology one that roams around Qld.
With 3D manufacture of crowns and plates etc., it would answer a lot of problems in this area which would concomitantly assist their general health, particularly the Diabetics.
The problem is, who would staff these Clinics ?
Well, since we can’t get Australian graduates to do it, what about the immigrant Dentists who come here , having to work in them for 1-2 years before they go to the “big smoke”–or is that being racist or discriminatory ?
What about Interns in their first two years after graduation, or would that be too stressful on the poor young graduate ?
It could be paid for out of the billions that currently are paid into indigenous welfare, instead of grog, drugs and poker machines ?
And pay them ridiculous wages, because of the difficulty in finding dentists to go—it will all come back in Taxation anyway.
Reply to Post 2 –
I agree = maybe all effective evidence-based care should be included within medicare – This should be central to planning future healthcare – “Better value care” https://www.health.nsw.gov.au/Value/Pages/default.aspx
As with general health and wellbeing, the social determinants of health and (oral) health literacy are critical inter-connected factors in population oral health care outcomes and the costs of dental care. As has been stressed, while dental decay and periodontal disease are largely preventable, the rates of disease continue to be relatively high. Again as has been stressed, the cost of treating these diseases and restoring aesthetic, functioning dentitions is extremely high due to facility, capital equipment, operational, staff and professional costs. If dental disease rates could be reduced along with the need for clinically-based dental treatment the national burden of dental care costs could be substantially reduced. Oral and dental diseases share many common risk factors with most chronic diseases along with interconnected pathologies. So the rightful call for an emphasis on prevention and primary health care should apply fully to oral health. Holistic care must include a focus on oral health as a critical component of general health and wellbeing. In an ideal world the dental clinic would be seen not as the initial point of contact but more as a surgical endpoint, not dissimilar to an operating theatre, to be avoided wherever feasible because of its cost and focus on disease.
As a practising Dentist of 34 years I read this article with some interest. As one review correctly states the costs of practising Dentistry are very high indeed, and that in itself is the issue in terms of providing care at a lower cost base. The governments of the day have endlessly talked about a “Denticare” system. Contrary to the author’s belief that Dentists may be unhappy with a public system, if we are saying there are literally millions of people unable to afford care then surely this in itself is a priority and most Dentists would welcome care being delivered to all not just the few that can afford it. The issue is that on past estimates the costs to deliver Dentistry on this scale would place a financial burden on the health system in excess of twice the levels that Medicare is currently funded to. Who will pay for it and from where? No government has resolved this. Better education for Doctors on the mouth is certainly important, but under the current system perhaps better communication between physicians and Dentists to enable our patients to receive the best possible care is definitely warranted.
Yes, dental treatment should be available on Medicare for certain groups (as it used to be on a GPMP) , perhaps with some restrictions.
But to say that excluding a part of medicine or the body is wrong , is it equally wrong to exclude allied groups such as physiotherapists, where same areas of treatment show superior efficacy to surgical procedures eg early OA knee and chronic back pain?
Dentists basically have to run their surgeries as if they were operating theatres. To fit out one room is in the hundreds of thousands of dollars.
They are subject to very high levels of compliance (and the costs associated with these)
Medicare should cover more of these costs.